Susan Jones, a retired insurance underwriter writing in the Guardian's letters section, delivers something rare in the NHS debate: a structural cost argument from someone who spent a career inside the insurance machine. Her case is arithmetic, not ideology. The core distinction is between two flavours of insurance risk. Home insurance covers events whose probability stays roughly flat over time — your house is about as likely to burn down this year as next. Medical insurance is the opposite: it covers events that become more likely with age. This makes it fundamentally different from casualty insurance and structurally harder to price fairly. The older and sicker you get, the more premium you need — and the less affordable coverage becomes precisely when you need it most. Insurers respond to this rising-risk curve with familiar tools: escalating excesses, co-pays, and pre-existing condition exclusions. These aren't bugs; they're the rational business response to adverse selection. Every insurer faces the same incentive: shed high-cost policyholders or price them out. The result is a system that works beautifully for the young and healthy and fails systematically for the old and sick. Jones then lays out the premium breakdown: roughly 60% goes to claims, 10% to administration, 20% to sales and distribution, 15% to shareholder profits, less about 5% from investment returns. An NHS-style system eliminates the sales and profit layers entirely. Even without the investment return offset, the public model runs approximately 30% cheaper on structural overhead alone. This aligns with decades of international evidence. The United States, the world's largest insurance-based healthcare economy, spends roughly 17% of GDP on healthcare versus the UK's approximately 10%, while delivering worse population-level outcomes on life expectancy, infant mortality, and preventable deaths. Administrative costs in the US system consume an estimated 15-34% of total healthcare spending, depending on how you count. The letter responds to a younger participant named Ted who advocated abolishing the NHS in favour of a social insurance model with free treatment at point of need and consumer choice over coverage levels. Jones doesn't dispute the appeal of that framing — she disputes whether the business fundamentals can deliver it. Choice-based coverage tiers inevitably produce a two-tier system: comprehensive coverage for those who can afford rising premiums, and stripped-down coverage with punishing co-pays for everyone else. The argument's power is its simplicity. It doesn't require you to love the NHS or ignore its problems. It requires you to accept that inserting a profit-seeking intermediary between patients and care adds roughly 30% in structural costs that must be paid by someone — and that someone is always the policyholder.
